Recipient

Liverpool Heart and Chest Hospital NHS Foundation Trust

First report 26 Sep 2018•Latest report 12 May 2021

Recipient record

Reports, concerns and published responses

Health and care · NHS trust. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports: 2
Published responses: 100%
Concerns addressed: 3
Stated actions: 16

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

100%published responses found

16stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Liverpool Heart and Chest Hospital NHS Foundation Trust linked to the concerns in each report. Select any concern, action or position to view the source wording.

12 May2021
Manchester South
Concerns raised1
1. Failure to ensure use of 3D reconstruction when reporting aortic stent surveillance CT scans
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Implement and circulate a formal policy requiring multiplanar views for reporting all relevant images.
  Stated completed
2. Action
  Perform and report relevant images in-house, retaining images demonstrating use of multiplanar reconstruction instead of outsourcing them.
  Stated planned
3. Action
  Conduct annual audits of compliance with the multiplanar-view reporting policy and present results to divisional governance meetings.
  Stated planned
AI-generated summary

MARY ANNE MELLOR · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Mary Anne Mellor died at Stepping Hill Hospital from a ruptured thoracic aortic aneurysm caused by a leak from an aortic stent. The leak was not identified on CT scans in 2019 and 2020 because 3D reconstruction was not used. Concern remained that other patients with aortic stents could be at risk of leaks not being identified, potentially depriving them of elective surgical management before life-threatening complications occurred.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Liverpool Heart and Chest Hospital NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation
Failure to ensure use of 3D reconstruction when reporting aortic stent surveillance CT scans
Wider context from the report
“(1) Following a thorough investigation, I HCH recognised that the leak was not identified on the CT scans in 2019 and 2020 because 3D reconstruction was not used when they were reported. LHCH have amended their reporting protocol for aortic stent surveillance accordingly and requested that Medica, who continue to report such scans for LHCH, do the same. However, as of the date of the inquest, LHCH had received no response from Medica and could not assure me that Medica are using 3D reconstruction to report this type of scan and/or intend to do so in future. (2) I am therefore concerned that other patients at LHCH with aortic stents remain at risk of leaks not being identified, potentially depriving them of elective surgical management before life threatening complications occur. ”
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Implement and circulate a formal policy requiring multiplanar views for reporting all relevant images.

Verbatim wording from the response
“In order to ensure this event does not reoccur, we have written a formal policy which has been approved and circulated to all relevant clinicians. In it, it states that all images of this nature must be reported using multi planar view.”

Source location
2021-0153-Response-from-Liverpool-Heart-and-Chest-Hospital-Redacted
Page 2 · response
Published 18 May 2021
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Perform and report relevant images in-house, retaining images demonstrating use of multiplanar reconstruction instead of outsourcing them.

Verbatim wording from the response
“Following the meeting held with Medica on the 19th May 2021, it was agreed that LHCH will perform and report in house for this type of image as we are able to store images that demonstrate MPR has been used and they will no longer be outsourced to Medica.”

Source location
2021-0153-Response-from-Liverpool-Heart-and-Chest-Hospital-Redacted
Page 2 · response
Published 18 May 2021
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Conduct annual audits of compliance with the multiplanar-view reporting policy and present results to divisional governance meetings.

Verbatim wording from the response
“In order to ensure this event does not reoccur, we have written a formal policy which has been approved and circulated to all relevant clinicians. In it, it states that all images of this nature must be reported using multi planar view.”

Source location
2021-0153-Response-from-Liverpool-Heart-and-Chest-Hospital-Redacted
Page 2 · response
Published 18 May 2021
Open published response
26 Sep2018
Manchester West
Concerns raised2
1. Failure to provide accurate referral destination information for aortic aneurysm treatment
2. Lack of approved documented pathways for referral and treatment of aortic aneurysms
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Angela Mary Jackson · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Angela Mary Jackson died at the Royal Albert Edward Infirmary, Wigan, after being admitted with chest and abdominal pain and found to have an extensive thoracic aortic aneurysm. She suffered a cardiac arrest and died while discussions about referral to an appropriate specialist centre were ongoing. The report identified concerns about incorrect and delayed referrals and the absence of clear, documented pathways for managing and referring patients with aortic aneurysms.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Liverpool Heart and Chest Hospital NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation
Failure to provide accurate referral destination information for aortic aneurysm treatment
Wider context from the report
“i. The treatment of an aortic aneurysm depends on the position of the aneurysm. In general terms aneurysms above the diaphragm are referred to as thoracic aneurysms and should be treated by cardiothoracic surgeons and aneurysms below the diaphragm are referred to as abdominal aneurysms and should be treated by vascular surgeons. The treatment of a thoracic aneurysm by a Cardiothoracic Surgeon may also depend on the position of the aneurysm above the diaphragm. An ascending thoracic aneurysm could be dealt with by local Cardiothoracic Surgeons at the Wythenshawe Hospital in Greater Manchester, whereas a descending thoracic aneurysm should be referred to and managed by the Regional Aortic Centre in Liverpool, namely the Liverpool Hospital. ii. The Wythenshawe Hospital referred to the Liverpool Hospital as the Liverpool Heart Centre and advised the Wigan Hospital to contact the Liverpool Heart Centre. Clearly, the Liverpool Heart Centre does not exist and the correct referral should have been to the Liverpool Heart and Chest Hospital. iii. There are no written protocols or pathways in relation to the treatment of aortic aneurysms in Greater Manchester or the North West of England, although the Preston Hospital has started to prepare a written Acute Aortic Syndrome Pathway. However, the Acute Aortic Syndrome Path is only in draft form, which has not been approved and which is not in existence. iv. The absence of documented pathways in relation to the treatment of aortic aneurysms is a national problem, which needs to be addressed to enable local district hospitals to be aware of the pathway and to have clear, unequivocal direction for referral of patients with appropriate and correct lines of referral, including the correct names of hospitals and direct telephone numbers and email addresses to ensure efficient and expedient referrals to appropriate hospitals and appropriate surgical teams. v. The referral of patients for the treatment of aortic aneurysm, in many cases, requires an urgent referral and emergency treatment and in my opinion there is a risk that future deaths will occur unless action is taken to consider clear and unequivocal pathways for the referral of patients requiring such treatment. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Liverpool Heart and Chest Hospital NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation
Lack of approved documented pathways for referral and treatment of aortic aneurysms
Wider context from the report
“i. The treatment of an aortic aneurysm depends on the position of the aneurysm. In general terms aneurysms above the diaphragm are referred to as thoracic aneurysms and should be treated by cardiothoracic surgeons and aneurysms below the diaphragm are referred to as abdominal aneurysms and should be treated by vascular surgeons. The treatment of a thoracic aneurysm by a Cardiothoracic Surgeon may also depend on the position of the aneurysm above the diaphragm. An ascending thoracic aneurysm could be dealt with by local Cardiothoracic Surgeons at the Wythenshawe Hospital in Greater Manchester, whereas a descending thoracic aneurysm should be referred to and managed by the Regional Aortic Centre in Liverpool, namely the Liverpool Hospital. ii. The Wythenshawe Hospital referred to the Liverpool Hospital as the Liverpool Heart Centre and advised the Wigan Hospital to contact the Liverpool Heart Centre. Clearly, the Liverpool Heart Centre does not exist and the correct referral should have been to the Liverpool Heart and Chest Hospital. iii. There are no written protocols or pathways in relation to the treatment of aortic aneurysms in Greater Manchester or the North West of England, although the Preston Hospital has started to prepare a written Acute Aortic Syndrome Pathway. However, the Acute Aortic Syndrome Path is only in draft form, which has not been approved and which is not in existence. iv. The absence of documented pathways in relation to the treatment of aortic aneurysms is a national problem, which needs to be addressed to enable local district hospitals to be aware of the pathway and to have clear, unequivocal direction for referral of patients with appropriate and correct lines of referral, including the correct names of hospitals and direct telephone numbers and email addresses to ensure efficient and expedient referrals to appropriate hospitals and appropriate surgical teams. v. The referral of patients for the treatment of aortic aneurysm, in many cases, requires an urgent referral and emergency treatment and in my opinion there is a risk that future deaths will occur unless action is taken to consider clear and unequivocal pathways for the referral of patients requiring such treatment. ”
Open source report

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026

Reports, concerns and published responses

Reports over time

Concerns raised1

Failure to ensure use of 3D reconstruction when reporting aortic stent surveillance CT scans

Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised.3

Concerns raised2

Failure to provide accurate referral destination information for aortic aneurysm treatment

Lack of approved documented pathways for referral and treatment of aortic aneurysms

Actions described in response 3